H-Madness is intended as a resource for scholars interested in the history of madness, mental illness and their treatment (including the history of psychiatry, psychotherapy, and clinical psychology and social work).

The most recent issue of History of the Human Scienceshas Scott Vrecko as guest editor and is dedicated to Neuroscience, Power and Culture Contents. Two articles adresses more specifically the use of drugs inside psychiatry.

The persistence of the subjective in neuropsychopharmacology: observations of contemporary hallucinogen research by Nicolas Langlitz (Department of Anthropology, New School for Social Research). The abstract reads:

The elimination of subjectivity through brain research and thereplacement of so-called ‘folk psychology’ by aneuroscientifically enlightened worldview and self-conceptionhas been both hoped for and feared. But this cultural revolutionis still pending. Based on nine months of fieldwork on the revivalof hallucinogen research since the ‘Decade of the Brain,’this paper examines how subjective experience appears as epistemicobject and practical problem in a psychopharmacological laboratory.In the quest for neural correlates of (drug-induced alteredstates of) consciousness, introspective accounts of test subjectsplay a crucial role in neuroimaging studies. Firsthand knowledgeof the drugs’ flamboyant effects provides researcherswith a personal knowledge not communicated in scientific publications,but key to the conduct of their experiments. In many cases,the ‘psychedelic experience’ draws scientists intothe field and continues to inspire their self-image and wayof life. By exploring these domains the paper points to a persistenceof the subjective in contemporary neuropsychopharmacology.

Profitable failure: antidepressant drugs and the triumph of flawed experiments by Linsey McGoey (Saïd Business School, University of Oxford). The abstract reads:

Drawing on an analysis of Irving Kirsch and colleagues’controversial 2008 article in PLoS [Public Library of Science]Medicine on the efficacy of SSRI antidepressant drugs such asProzac, I examine flaws within the methodologies of randomizedcontrolled trials (RCTs) that have made it difficult for regulators,clinicians and patients to determine the therapeutic value ofthis class of drug. I then argue, drawing analogies to workby Pierre Bourdieu and Michael Power, that it is the very limitationsof RCTs — their inadequacies in producing reliable evidenceof clinical effects — that help to strengthen assumptionsof their superiority as methodological tools. Finally, I suggestthat the case of RCTs helps to explore the question of why failureis often useful in consolidating the authority of those whohave presided over that failure, and why systems widely recognizedto be ineffective tend to assume greater authority at the verymoment when people speak of their malfunction.

The successful passage of health insurance reform legislation in the United States moves me to wonder about the extent to which scholars have looked into the role of health insurance in mental health care. About ten years ago, a number of us historians examined the impact of mental illness on social insurance in Germany around the years 1880-1930. Perhaps not surprisingly, the rise of shellshock in World War I and the killing of 200,000 psychiatric patients by the Nazis under their T-4 program provided the backdrop and inspiration for much of this research. In my own study of disability within early German social insurance (Making Security Social), I found that providing health care benefits to those suffering from work-related nervous illnesses prompted a vocal, organized, and persistent backlash from those who contended that the system was only rewarding malingering. The fact that some claimants contended that their nervous symptoms were caused, not by a factory accident, but rather by the torturous process of applying for a pension itself only seemed to confirm the view that social insurance and mental illness did not mix well. In fact by the 1920s and 1930s, « pension neuroses » – as they were called – were publicly pilloried by conservatives, liberals, and the Nazis as emblematic of a social insurance system that bred whining and undermined productivity and masculinity. Interestingly enough, however, the Nazis found it politically impossible to dismantle the social insurance system, despite the fact that many reformers in their party wished to do so. So, there is certainly historical evidence indicating that, indeed, insurance systems do create new constituencies that provide powerful support for the system’s continuation.

So, I have some questions for others. Are there good historical studies out there (articles or monographs) which examine insurance’s impact on mental illness and mental health and vice versa? What role has health insurance played in reinforcing or undermining professional, institutional, and social trends and practices? For instance, to what extent was social insurance responsible for the post-World War II boom in psychotherapeutic professionals and services? What role have pharmaceutical companies played in health insurance systems affecting mental health across the globe? What effects did health insurance schemes have on the process widely known as deinstitutionalization? Please post any responses on the blog.

The notion of obsession was built late in France. The same is true in German-speaking countries (first occurring in 1867). But obsessional disorders have kept a more autonomous nosographic position in these latter countries than in France, where obsession has long been connected with the idea of degeneration, which is not given emphasis in Germany. Mentioned for the first time by Krafft-Ebing in 1867 and by Griesinger in 1868, obsession (Zwangsvorstellung) has been the subject of an exemplary clinical description by Westphal, in 1877, who defined it as an autonomous pathology radically different to “paranoia” (Verrücktheit) and melancholia; according to him, obsessions never change into delusions. This field has varied considerably in its symptomatic area: some authors going so far as to introduce the idea of obsession, sensations, feelings, impulses, and actions; obsession, according to Löwenfeld, encompass the intellectual, emotional, and motor functional spheres. Other authors, notably Bumke, keep to a more strictly defined area, within the direction defined by Westphal. Fundamental emotional disorders are either rejected or identified with anxiety. Connections with other illnesses have given rise to a number of concepts. Considered autonomous by Westphal and Bumke, obsessional symptomatology has been thought of, by other authors as primary or secondary to other pathologies, originating in melancholia or changing into it. The nosographic position varies. Either obsession is considered an autonomous illness or it is connected to other pathologies (neurasthenia, degeneration, Verrücktheit). Connections with other illnesses are dominated by relationships to melancholia; connections to paranoia are much more problematic; those with hysteria are seldom mentioned. After setting up frameworks for manic-depressive psychosis and schizophrenia (Kraepelin, Bleuler) and for hysteric neurosis (Freud), the nosographic position of obsessions, which have become “obsessional neurosis”, varies according to these pathologies and becomes complex. Kraepelin has it as an anxiety disorder connected to phobias but links some obsessions with “manic-depressive insanity”. The followers of Kraepelin insist on the connection with manic-depressive illness. Bleuler connects the obsessions to schizophrenia-schizothymia. These relations between obsession and schizophrenia give rise to abundant literature. Their links are located at a psychopathological level (“Spaltung,” the defense, slowing down, repairing and recovery from schizophrenia), at a symptomatological level (pedantry-mannerism, schizophrenic autism-closed aspect of the obsessed, their motor disorders-catatonia), or at a clinical level (obsession-schizophrenia association). Obsessions are considered by other authors as personality disorders. Notably by Kretschmer (sensitive reaction) or by Schneider as a psychopathic personality: anancastics, second subgroup of the self uncertain psychopaths. As for the anthropological-existential point of view, it tackles the patient with obsessive disorders in his or her totality and analyses the transcendental constitution of his or her world.

Since the early twentieth century, when Alois Alzheimer and Emil Kraepelin constructed it as a unified clinical-pathological entity, Alzheimer’s disease has been both one of the most stable and one of the most problematic neuropsychiatric entities.

Alzheimer’s (listed as Dementia of the Alzheimer’s Type in DSM-IV) remains one of the very few instances in which psychiatry has managed to associate a well-defined clinical syndrome – global deterioration of cognitive ability – with clear-cut brain pathology – the senile plaques and neurofibrillary tangles that continue to be regarded as the essential biomarkers of the disease.

And yet it has been one the most problematic of disease entities because – despite the relative clarity around its clinical symptoms and pathological correlates – a clear boundary has not been established between Alzheimer’s and aging. The cognitive deterioration that defines Alzheimer’s and other forms of dementia is experienced by everyone as they age, though to a much lesser degree in people not diagnosed. Similarly, decades of accumulated autopsy evidence has demonstrated that the plaques, tangles and all other putative biomarkers for Alzheimer’s and other major forms of dementia are found to varying degrees in all aging brains.

Thus on evidentiary grounds, at least as good a case can be made for viewing Alzheimer’s as an endpoint on a spectrum of cognitive changes associated with normal aging as for viewing it as a disease. But for political reasons, since the 1970s psychiatrists, neurologists, and Alzheimer’s advocates in the United States and Europe, have overwhelmingly asserted that it should be regarded as a disease. These political reasons can be summed up succinctly: government funds research for dread disease, not for discovering the fountain of youth. And as a political construct, Alzheimer’s as dread disease has been wonderfully successful at winning federal funding for research.

But critics – most notably neuroscientist Peter Whitehouse and anthropologist Daniel George in the their book The Myth of Alzheimer’s, have argued that the Alzheimer’s disease construct represents the medicalization of brain aging and profoundly exacerbates the stigmatization of age-associated cognitive decline.

To no one’s surprise, the draft of DSM-V does not back off of the commitment to viewing Alzheimer’s and similar conditions as disease entities distinct from aging. But it does propose two significant changes that, while well-intentioned, may greatly extend the medicalization of aging and worsen the stigma of age-associated cognitive decline.

Perhaps the most dramatic change related to these conditions in the draft DSM-V is the proposal to drop the term “Dementia” and replace it with the term “Major Neurocognitive Disorder.” The stated rationale for the proposed change mostly focuses on nosological considerations that seem on the whole sensible to address. But interestingly, the rationale also notes that the term dementia has “acquired a pejorative or stigmatizing connotation.” For just this reason, even critics of the Alzheimer’s disease construct seem to be welcoming this proposed change (for example, see the comments to the Myth of Alzheimer’s blog post on DSM-V changes.)

I am less optimistic that the ostensibly more neutral language of neurocognitive disorder will significantly lessen the stigma associated with Alzheimer’s disease or the milder cognitive impairments associated with aging. To be sure, the label dementia is deeply stigmatizing. But its stigmatizing power comes not from the word itself but from a deeper cultural impulse of marginalization. As long as we judge the worth of human beings by normative standards of productivity and competence, any label used to denote an impairment that prevents an individual from meeting those standards will soon enough come to be stigmatizing. Absent any meaningful attempt to change the normative standards that drive the stigmatization of aging and cognitive impairment, changes in terminology will not be de-stigmatizing but merely euphemistic. To the degree that the deployment of euphemism allows us to ignore unpleasant realities and shirk difficult social and cultural work, it will do more harm than good.

The other major change related to age-associated cognitive deterioration in the draft DSM-V is the proposal to add the category “Minor Neurocognitive Disorder” to recognize “the substantial clinical needs of individuals who have mild cognitive deficits in one or more of the same domains but can function independently… often through increased effort or compensatory strategies.”

The creation of the “Minor Neurocognitive Disorder” is an especially worrisome example of what, in a post to h-madness a couple of days back, Allan Horwitz characterized as a “Trojan horse that would diagnose nearly a-symptomatic people as being in the early stages of a disorder.” While such early diagnosis and treatment might be a well-intentioned effort to make help available early on, or to enhance investigation of the causes of a disorder, it has clear potential for abuse by a pharmaceutical industry eager to expand the market for their goods. This potential can be seen in the stated rationale for the proposal, which notes that early recognition of

“Mild Cognitive Impairment may be particularly critical, as it may be a focus of early intervention. Early intervention efforts may enable the use of treatments that are not effective at more severe levels of impairment and/or neuronal damage, and, in the case of neurodegenerative disease, may enable a clinical trial to prevent or slow progression.”

This is a fairly transparent statement of the hope that the drugs found to be of dubious value to patients diagnosed with Alzheimer’s disease might be found to offer greater benefit to patients in prodromal stages – or at least to generate more profits for drug companies.

The proposed diagnostic criteria for Alzheimer Subtype of Major or Minor Neurocognitive Disorders in the draft DSM-V stops just short of endorsing Mild Cognitive Impairment (MCI) as a prodrome of Alzheimer’s disease. The stated rationale for the proposal notes that research is ambiguous. Patients with MCI in memory disorder clinics have been shown to progress to Alzheimer’s at a rate of 12-15% per year, but population-based studies show a much lower rate of progression, with some individuals actually improving. Thus, the predictive value of MCI (or what under DSM-V will be called Minor Neurocognitive Disorder with Memory Impairment) does not warrant an automatic diagnosis as prodromal Alzheimer’s disease. The diagnostic criteria require not only evidence of mild memory impairment, but “clear supporting evidence for the Alzheimer etiology (e.g., a positive test for a known mutation in an Alzheimer’s disease associated gene), or with evolving research, documentation based on biomarkers or imaging.”

A positive test for one of the Alzheimer’s genes is a high diagnostic hurdle that would function to prevent dramatic inflation of this diagnostic category, but given the value to many powerful interests of very early Alzheimer’s diagnosis, who can doubt that progress in biomarkers and imaging will be quickly forthcoming? Smart money should be investing in pharmaceutical companies that stand to tremendously enlarge the market for drugs that have proven to be of dubious value for people diagnosed with Alzheimer’s.

And once every senior moment is diagnosable, we really will have reached the point – as Horwitz right worries – of pathologizing everyone.

This evening, France 2, a French public national television channel, will broadcast a documentary inspired by the Milgram experiments in the 1960s. « Le jeu de la mort », signed by Christophe Nick, transposed to the television the experiment at Yale University by Stanley Milgram in the 1960s to probe the mechanisms of the submission of the Nazi Germans. For this experiment, 80 volunteers who had never attended a game show were recruited. They were told that they participate at a new entertainment-show called « Xtreme Zone ». The goal: to submit a candidate – in fact a comedian – to a series of questions. The punishment? An electric shock ranging from 80 to … 460 volts. With each wrong answer, the public also recruited, cries « punishment ». . 80% of questioners go to the end of the game as it becomes a torture session. Only 16 candidates have abandoned the game resisting the authority of television. The documentary has raised a major debate in France on reality shows and the power of television.

The original DSM series was motivated by an attempt to correlate several conflicting classification schemata (such as still persist in the ICD). However, since the American Psychiatric Association was taken over by a set of narrow specialists in neurobiology in the 1940s (Kirk and Hutchins) it has become an ever more inflexible instrument. In general – with a few notable exceptions such as the grudging acceptance of homosexuality as normal behavior (the topic of a brilliant episode of This American Life) – each edition has been worse than the last. The new edition promises to continue this proud trend.

Before going into some particular changes for this edition, let me rehearse two problems with the entire set. A significant logical flaw is that it is entirely self-fulfilling: psychiatrists, psychologists and patients can only get re-imbursements for sessions attached to a specific DSM diagnosis. There can be no disagreement with the code, even if the whole is largely flawed. In my own experience and that of my friends, this generally means that we sit down with our psychiatrist during a session and choose a code which will do relatively little professional damage if it gets out, and will provide the drugs that she and I prefer. I know a large number of psychologists and some psychiatrists (the non-pill-pushing variety) who find this a tad abhorrent. Further, and again I’ll speak for myself as patient, I find the current set of available conditions massively restricting. When going through what your average Australian would call a ‘rough spot’ several years back, I was offered variously diagnoses of depression, hypermania, hypomania, manic depression, ADHD, anxiety, hyperthyroidism and anhedonism – I deeply prefer the nineteenth century offerings of melancholic, bustling, a delicate sort: each with their own social acceptance and romantic overtones. Bateson’s definition of information (a difference which makes a difference) does not obtain here, since most ascriptions of these classifications lead to the prescription of a very small set of drugs.

I am feeling ever more constrained to always keep my behavior within acceptable limits. In the nineteenth century I could, in my Sherlock Holmes persona – but maybe I’d better not talk about that one – fall into a black depression, shoot up some cocaine and play the violin then come out of my funk and rid the world of Moriarity. Today, that archcriminal would quickly get me hospitalized. In short, the medicalization of deviance – a term first deployed in the 1970s – is in its heyday. Where the United States still manages to see itself as a haven for liberty, I wonder how one can maintain that rosy façade in the face of the medicalization of the minds of most of our population and the largest incarceration and execution rate (the only really competing paradigm in the United States to DSM is mortal sinners vs nice people) in the developed world.

Enough of a rant perhaps. Let’s take as given a tradition of not recognizing social, communal and family dimensions of difficult internal lives of citizens. I find it hard to be truly beatific in a world bent on ecological self-destruction and living in a society bent on unjust wars and providing no safety net for its poorest citizens so that many die unnecessarily, but I guess that’s my fault. It’s sad, but fortunately I have some happy pills.

I actually rather like the potential dissolution of Asperger’s syndrome into Autism Spectrum Disorder – despite the shocked reaction of parents of some computer geeks, who are often characterized by some forms of behavior associated with Asperger’s (just visit the Google campus for a day to verify this). These are clearly part of a package of behaviors which run the full gamut from what should be considered normal to that which is definitely problematic. If I had a general theory of what is called mental illness I would take this principle as a baseline: it’s spectrums all the way down. That’s what multidimensionality is all about. I do find some fault with Susan Swebo’s report though – what exactly does it mean to cleave to a principle that collapses without disambiguating:

« How to address Pervasive Developmental Disorders – Not Otherwise Specified (PDD-NOS). The individuals currently diagnosed with PDD-NOS may still be described in DSM-V, but the work group will discuss whether they can redefine ASD in such a way that the PDD-NOS diagnosis isn’t necessary, as this diagnosis currently captures a very heterogeneous group of individuals.«

If I understand the logic of this (though I’m getting depressed as I write so please don’t pay any attention to me), this means that a heterogeneous group of individuals will become homogeneous (which basically means treated by the same drugs) if we wiggle the definition of ASD. And this is seen as a breakthrough rather than sweeping interesting problem cases under an available carpet?

I am not totally negative about this revision. Indeed, I close on a somewhat hopeful note. There are revisions being suggested to the definition of just what a mental disorder is, which include:

« C Must not be merely an expectable response to commonstressors and losses (for example, the loss of a loved one) or a culturally sanctioned response to a particular event (forexample, trance states in religious rituals)

D. That reflects an underlying psychobiological dysfunction

E. That is not primarily a result of social deviance or conflicts with society«

If in practice we really honored C and E and defined D in some useful way (which would have to go way beyond psychobiological) then we might work towards a socially useful and culturally rich treatment of mental disorders. First, though, the psychiatric community needs to come up with rich treatments of C and E, since currently childhood deviance or conflict is not seen in this way (even though it’s of the nature of adolescence) and the set of ‘common stressors’ and ‘culturally sanctioned’ do not include living in an overcrowded world (which we know, through rigorous study, causes problems for rats).